Nurse Education in Practice xxx (2014) 1e7
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience Laura Sabatino a, *, Gennaro Rocco b, Alessandro Stievano b, Rosaria Alvaro a a b
Tor Vergata University, Rome, Italy Centre of Excellence for Nursing Scholarship, Ipasvi Rome, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 11 September 2014
This research explored the perceptions of third-year undergraduate nursing students in Italy in relation to the perceptions they had about factors that promoted or diminished the development of professional identity and the professional respect in themselves, and in nursing during their clinical training. Clinical training was meaningful to develop specific knowledge, communication skills, and interpersonal and inter-professional relationships in the area considered. It was also found to be equally important to have good role models to foster the moral development and build a solid professional identity for nursing students. Building a professional identity is an ongoing process and depends on social contexts and on the students' development of the ability to act morally. In this framework, student nurses have to be strongly supported to develop their identity as moral agents in spite of the conflicting demands on them in hostile settings that often do not make them feel respected for their actions. Based on our evidence, we identified two conceptual areas: positive role models and supportive working environments; both have to be strongly connected each other if the student nurses have to develop a strong respect for the ethical values of their profession. © 2014 Published by Elsevier Ltd.
Keywords: Clinical environment Clinical placements Role modeling Student nurses
Introduction The development of professionalism in clinical practice and the n and Segesten, 1998; ten building of professional identity (Ohle Hoeve et al., 2013) is an ongoing process that goes on throughout the individual's professional life, a relational process arising through social contexts (Hartrick Doane, 2002; Varcoe et al., 2004) and student nurses' development of moral identity and of their abilities to act morally are relationally and contextually dependent. It is in the early undergraduate years that this process begins and assume a very strong value for the upcoming years. Good professionalism in practice presumes a process of professional identity construction and professional identity is an important element to gain professional respect (Sabatino et al., 2014). The development of professionalism for nursing, that in Italy for undergraduates take place especially in tertiary health care facilities,
* Corresponding author. E-mail addresses: [email protected] (L. Sabatino), genna.rocco@gmail. com (G. Rocco), [email protected] (A. Stievano), [email protected] (R. Alvaro).
that are still the principal places where students can have their clinical placements, has to be based on positive role models (Donaldson and Carter, 2005) and supportive clinical environments that, through their interconnectedness and strong linkage, play a pivotal role to develop professional behaviors and ethical values. In fact, it is in clinical placements (Edwards et al., 2004; Hamshire et al., 2012) that students learn the required knowledge, together with the technical and relational skills to identify, interpret and cope with the problems of health of the general public (Holland, 1999). In these clinical environments, which enhance their knowledge and skills from qualified nurses and other health professionals and peers, the nursing students learn how to develop strong ethical and professional values. The importance of positive role models (Perry, 2009) on student nurse professional development cannot be overestimated. Some articles on role modeling highlight students' experiences of being exposed to both good and bad role models (Baldwin et al., 2013; Ferguson, 2011; Grealish and Ranse, 2009; Perry, 2009). Students observing an exemplary nurse can convert the observation into a positive action through modeling because, according to the third principle of Bandura's Social Learning Theory:
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Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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“individuals are more likely to adopt a modeled behavior if the model is similar to the observer and has admired status” (Bandura, 1977, p. 30). Despite being fully committed to their practice placement educator role, even the best clinical teachers can be diminished in their role by poor learning environments. Permanent cognitive conflict between theory and practice can lead to the development of insecure identities. The self-awareness of students' own professional respect is still vague and attenuated early in their placements, liable to be detrimental to the nursing profession by remaining subordinate in practice and perpetuating the chasm between theory and practice (Rolfe, 1998). In Italy, the basis of registration for nurses has been a compulsory three-year university degree since 2001 and there has been a marked increase in the professional qualifications of nurses since then. However, despite this raised education experience, the clinical atmosphere is still too often linked to the previous traditional nursing diploma culture and heritage in many clinical learning environments. This relies on the traditional ward routines and other health professions and professionals dictating the rules. As mentorship is widely accepted as a cornerstone for the preparation of professionals in practice it not surprising that in such contexts the students feel unsupported by their clinical facilitators (Andrews and Chilton, 2000; Andrews and Roberts, 2003; Haigh and Johnson, 2007). Within this framework, the aim of this study was to describe the students' perceptions of professionalism in clinical practice and the construction of professional respect through observed behaviors. The participants observed clinical teachers, qualified nurses, student peers and other health professional staff during their clinical placements. There is a compelling need to understand better what prompts the development of professionalism and hence nursing professional respect at an international level, and especially in a country where nursing science still tries to emerge from a deeply ingrained biomedical milieu. Methodology The research design and the main aim of the study was underpinned by three main questions to the students: 1. Can you give an example from your clinical learning setting where professional respect was either violated or regarded as an important value by nursing students? 2. Can you give one example of behavior by some nurses that could be considered as lacking or reinforcing professional respect? Please describe the event. 3. Have you ever witnessed a situation where the behavior of another health professional (physiotherapist, speech therapist, radiographer etc.), support staff or clerical staff either damaged or reinforced nurses' professional respect? Can you give an example?
Research design In this qualitative study we adopted an inductive content a, 2013), analysis approach (Granheim and Lundman, 2004; Saldan using focus groups technique to collect information about the elements which could strengthen or weaken the construction of nursing professional respect from the student nurses points of view.
Ethical approval Prior to the study, written and verbal information was given to the informants about the purpose and nature of the study, emphasizing that participation was voluntary and confidentiality and anonymity was guaranteed. Their right to withdraw without prejudice at any time was also emphasized. Ethical approval was obtained from the Directors of the Nursing Schools involved to conduct the study. Sample The nursing degree programme in Italy is organized according to the credit block system set up by the Bologna Declaration (Dante et al., 2013; Davies, 2008) and during the three years course approximately five months a year are dedicated to theory and six months a year are dedicated to practical clinical training. Clinical learning placements usually begin in general units (internal medicine wards), then move to more complex units (intensive care, neurosurgery, orthopedic surgery otorhinolaryngology, transplant surgery, etc.) and community settings (mental health, home care). In the area considered, community settings are scarcely attended by students. A purposive sample of seventy (n ¼ 70) Italian nursing students, at the conclusion of third year of the nursing degree course, in three different universities, were interviewed. We conducted ten focus groups in eight different nursing schools linked to the main universities in the Roman area. In each focus group there were between 6 and 8 participants. 43 of them were females and 27 were males. This high percentage of males nursing students reflects the trend in Italy who has been showing an increase of the participation of the males in nursing profession in the last 20 years. Nowadays, at the average national level about 24% of the nurses population is composed by male nurses (Federazione Nazionale Collegi IPASVI, 2012) and the situation varies between regions. In the southern areas of the country, due to the high unemployment rates, the nursing workforce population is composed of more than 40% of male nurses in Sicily and Campania just to have some examples (see Table 1). Data analysis A qualitative descriptive approach was used in this study, following Graneheim and Lundman (2004) method of analysis. Content analysis is often used to analyze large amount of narrative data, complex and sensitive phenomena that are multifaceted and difficult to comprehend (Vaismoradi et al., 2011). The focus groups were tape recorded and transcribed verbatim. Subsequently, the text was divided into meaning units that explored the development of professionalism and the meaning of Table 1 Participants' characteristics (n ¼ 70). Universities involved in the area: Tor Vergata University Rome (Italy) e Sapienza University Rome (Italy) e Sacred Heart Catholic University Rome (Italy) Focus groups Participants Student nurses Student nurses Age range Age mean Year of the nursing degree course
10 Total ¼ 70 F ¼ 43 M ¼ 27 21e45 25 3rd
Student placements of clinical practice: intensive care, neurosurgery, orthopedic surgery otorhinolaryngology, transplant surgery, maternity ward, oncology, mental health, urology, etc.
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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professional respect for undergraduates. The meaning units were then coded and grouped together. Initially, many different codes were created, but as the analysis progressed, these were clustered and reduced. Thereafter, sub-categories were formulated and it was then possible to develop four major categories from the subcategories. a, 2013), in the second cycle After this first cycle coding (Saldan coding, two researchers involved in the study repeated reading, reflecting, and validation of codes and categories, moving forwards and backwards between the growing categories and the text. Subsequently, two overarching interlinked themes became evident through a process of abductive analysis (Lipscomb, 2012). Throughout the whole analysis process, the authors compared and discussed the meaning of preliminary codes and categories until consensus was reached. Findings The findings are presented as two major themes, that contribute to develop the perceptions of Italian student nurses on the concept of the development of professionalism and professional respect during their clinical practice: (i) Cultural approach and health professionals' role modeling (ii) Organization of the clinical learning environment. The Fig. 1 provide a synoptic framework of the main categories and the two main emerging themes. Cultural approach and health professionals' role modeling. This theme is composed of three sub-categories: qualified nurses, student peers and other health professionals' role modeling; interprofessional relationships; and social considerations of the image of nurses portrayed by the media. Qualified nurses, student peers and other health professionals' role modeling Observing the behaviors adopted by nurses who worked in wards where students were having their clinical placements allowed the students to build an image of professionalism; students who participated in the interviews observed both negative and
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positive behaviors. Some of the negative behaviors can be easily identified: There were some nurses who shut themselves away in a room while at work, leaving the students alone. They seemed to be discussing their own personal problems. They were heard all over the ward and some patients and relatives came near the room and asked: ‘What's all this shouting about?’. (Focus group 10) The nurse told me to be down-to-earth and hence she wanted me to wash the patient with the same sponge all over the body, even the face. I told her this was not hygienic and she answered me that nurses have to be practical. (Focus group 8) The student nurses witnessed some of the negative behaviors during their learning placements and they felt embarrassed to communicate these during the interviews. There was a nurse … singing, singing, singing … and this lady was dying … she dismissed all the relatives … and still she was singing. (Focus group 2) (A nurse to a student) … ‘To this bloke do like this … with water, because he is a convicted criminal and who knows what he was up to in his life and he doesn't deserve anything’. (Focus group 5) Student nurses affirmed that in a particular unit nurses used two diapers for bed-bound incontinent patients so that they needed to change diapers less frequently and only when both were soaked with liquid: Going into a room, there was a man completely soaking in his urine and that man had double diapers. (Focus group 8) Student nurses related some episodes where they assisted other nurses and affirmed that they were ashamed of having had their clinical practice with these clinical teachers: “(A nurse) … What a bore! And now stop it! It is ten times you are calling, now I'm taking out your bed alarm!” (Focus 5).
Fig. 1. The overarching main themes and categories that contributed to perceive nursing professional respect in nursing students in Italy.
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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“Two nurses were making fun of a comatose patient … they were singing lullabies with the name of the patient in front of him” (Focus 1). Often student nurses told some poor episodes involving older or vulnerable patients: “(A nurse) Came near to the bed, put hands on her face and shut her up with profanities” (Focus 6). “The nurses in the early afternoon usually left the elderly patients dirty and their reason was that the nurses in the previous shift had left the patients dirty and they didn't want to do the job of other people!” (Focus 2).
I liked that qualified nurse very much because she showed true professionalism. She administered drugs …. She made a mistake and she took on her responsibilities. (Focus group 6)
Social considerations about images of nurses portrayed by the media The students believed that nurses have a low social status, which harms their professional dignity and that their image is flawed by the media, playing an important role in shaping the nursing profession in society: “(Nurses) They are there slammed in the headlines, under pressure by media, for things that are accomplished by a minority of them” (Focus 6).
Even some behaviors of head nurses are indicated as offensive of the professional respect towards undergraduates and their learning needs:
“The image of the female nurse is linked to the erotic image” (Focus 3).
“Ok, take the broom and sweep over there, take the rags and go to clean windows panes; this is not absolutely dignified for us (student nurses)” (Focus 10).
Sometimes, it is the relatives or significant others of patients that let student nurses be aware that they are not well thought about:
Third year nurse students underlined that the image provided by their peers to the general public is very important to endorse respect for the nursing profession. The behaviors of other student nurses represented an element of great debate in the different focus groups. It is not necessary that you have to go to your clinical practice with full make-up, perfumed, and with long nails, as seems to be common nowadays. (Focus group 10) A student nurse was always coming to clinical practice in a dirty uniform and with dirty hair. Our appearance is reflected in our work. (Focus group 7) Instead of taking care of patients and talking with the patients, this female student nurse told me how she spent her Saturday evening … in front of the patients. (Focus group 9) I saw student nurses follow the example of some senior nurses in disconnecting the bed alarm or to take it away completely. (Focus group 6) During their clinical placements some student nurses tried to see who were the exemplary nurses in order to learn useful skills and avoid being used to carry out mundane activities not suitable for their clinical education: We (students) who are in training have to learn the best from nurses who are offering the best. (Focus group 2) I gave up going on rounds with her (a nurse) because I was ashamed of her. (Focus group 3) The positive behaviors of qualified nurses strengthened the professional respect of the student nurses: That nurse, at the beginning of her shift, always did a complete round of patients to evaluate their conditions. (Focus group 3)
… Fantastic nurses who smiled at patients. They had a way of doing things and behaving that you (student nurse) would have liked to go to the clinical placement every day, even on Sundays. (Focus group 9) (Some nurses) would like you to be integrated and they always try to involve you and often ask: ‘What do you think of this procedure? How would you do it?’. (Focus group 9)
“They call us whistling, maybe they consider us a flock of sheep” (Focus 7). “The nurse is seen as a non-autonomous professional, someone who obeys the physician rules and prescriptions, that is to say, a subordinate, as he/she had not a professional identity” (by patients) (Focus 1).
Organization of the clinical learning environment Clinical learning environment. Student nurses highlighted a series of interconnected strengths and critical points of clinical learning environments that could be matched with the behavior of positive and negative role models in clinical placements. In the clinical learning environment, there are varieties of comportments that can significantly foster and hinder the clinical learning among undergraduates at the entry level. Many students experienced the uneasiness of not being able to behave as they would have liked, in fact, some of them, highlighted different situations where nurses used different procedures. In many cases nurses did not work on evidence based practice or were not aware of the best evidence: “Mercurochrome on pressure ulcers, the nurse gives it to you and you use it even if you know that is not beneficial for the patient, on the contrary, it deteriorates the skin” (Focus 1). “(A student nurse) … While she (a nurse) was beginning to have this technique, I put on gloves and I was told off, because gloves to take a blood sample are not necessary (she said), you can use only gloves to give an i.v. injection” (Focus 9). “The role of the professional … has got its own dignity but this dignity has to be demonstrated in practice. What you study is different from what you see. (Focus 6). An organizational factor was that the student nurses were clearly being treated as members of the workforce rather than persons involved in education: “(A nurse) Very well, it is nice! Students have come and I'm going to take a coffee” (Focus 5). “When we (student nurses) are present in the units, almost no-one answers to the bed bells: ‘Student where are you?’ (nurses shouting)” (Focus 5).
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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Even the exploitation of student nurses for non-nursing tasks, which have no educational purposes, was noted by students during the focus groups: That person (a head nurse) gives you menial tasks to do, such as cleaning cupboards, and she tells you: ‘When I am coming back I want to see them clean and tidy’. (Focus group 5) To send students to make coffee for everybody in the kitchen or, even to have coffee for everybody at the bar. (Focus group 6)
Discussion The two main themes, a cultural approach and health professionals' role modeling, and the organization of the clinical learning environment (Fig. 1), are strongly interconnected as emerged also in other studies (Mulholland et al., 2006; Papastavrou et al., 2010; Skaalvik et al., 2011). If the organization of clinical teaching fosters the partnership between clinical teachers and students (Saarikoski and Leino-Kilpi, 2002), the students will advance in understanding their professional identity (Andrew, 2012; Brennan and Timmins, 2012) and will be motivated to foster professional values (Keeling and Templeman, 2013). In good clinical working environments the relationship with clinical teachers who can role-model constructive feedbacks is pivotal. This allows students to convert observed behaviors into their own behaviours (Donaldson and Carter, 2005) and in this way nurture confidence and professional respect in undergraduates. The preparation of staff in the clinical area where students are placed is acknowledged as a key component for learning (Henderson et al., 2009). This supports the importance of educating clinical teachers among the most motivated and exemplary health professionals. Excellent workplace learning environments are vital for the development of knowledge and skills of the student nurses. The move to higher education for nursing in Europe (Lahtinen et al., 2013) and worldwide should be reflected in policies that foster the education of competent clinical teachers who can address and eliminate the bad practices and unacceptable moral behaviours in clinical placements and have the students' interests at heart. If sensitively handled, even bad comportments can have a positive influence on undergraduates (Grealish and Ranse, 2009). Supervision is a central element in clinical learning and without staff preparation and commitment to teaching (Andrews and Roberts, 2003) it is difficult to foster and develop in the students a sense of professionalism and professional respect (Brown et al., 2012). Good clinical teachers have sound interpersonal abilities, are clinically competent and are good role models and encourage mutual respect (Kelly, 2007, p.887). This was clearly expressed by the undergraduates' expressions of disgust for bad role models and, conversely, the enthusiasm to see nurses show empathy, compassion, strong moral attitudes and a commitment to accomplishing their work (Donaldson and Carter, 2005). Student nurses have to be strongly supported by dedicated clinical teachers with a good attitude towards them. Effectively partnered relationships are preferable, in order to develop their identity as moral agents in spite of the conflicting demands in difficult settings that often question their ability to feel respected for their actions and that sometimes cause them anxiety and stress (Moscaritolo, 2009). The clinical learning environment with its living models plays a central role in developing professionalism and ethical values, such as professional respect for the nursing profession (Lundberg, 2008). To overcome the theory-practice gap e the chasm between what has been taught and what is practiced in the field e has too often become a source of anxiety.
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These various factors can facilitate the undergraduate students to make sense of acting morally and reflecting critically on their practice situations (Henderson et al., 2006). It is evident that the Italian students in this study experienced a degree of frustration, especially when considering the negative expressions by head nurses and physicians. These models showed a lack of respect for them and for the patients and did not foster professionalism and professional respect. After the students reported such negative behaviors by the staff, school mentors often showed formal concern, but little could have been or was done. The historically and institutionally embedded moral character of these working environments did not allow changing some culturally ingrained ways of acting. Clearly, the challenge in these environments is to develop a pedagogy that can foster student nurses to develop their moral agency and hence the respect for their profession. In these settings, the students expressed that the strengthening of professional respect is generated by the mastery of competencies. They were well aware that the ‘fuzzy nurses’ (Rolfe, 1997) of the millennium are more aware of their rights and have to hold the values associated with competencies in high esteem. In the clinical environments considered, the value of interprofessional collaboration (Duddle and Boughton, 2007) seemed to be a strong factor in showing professional respect. This is noted in the Italian code of ethics for nurses (Federazione Nazionale Collegi IPASVI, 2009). Article 41 states: ‘Nurses collaborate with their colleagues and other health workers, recognizing and valuing their specific contribution within the team’; but this was not evident to the students during their clinical placements. The negative scenario grew worse when the students affirmed that they assisted in the violation of vulnerable persons. They clearly stated that even if they opposed (Bradbury Jones et al., 2011) the attitudes of nurses who wanted them to act against professional values, thus offending the students' professional dignity and behaving as bad role models, the students were mostly unable to withdraw from partaking in improper procedures. All they could do was to tell their mentors of the critical situations they encountered (Levett-Jones and Lathlean, 2009). The fear of a negative evaluation resulting in retribution (Bradbury Jones et al., 2011; Mansbach et al., 2013) sometimes led the students not to express their opinions clearly. Their discontent was then connected to feeling lonely and to learning without proper supervision. The students in this study complained a number of times about the lack of committed clinical teachers who could facilitate the translation of theory into practice (Gidman et al., 2011; Dal Prato, 2013). Finally, the social context of nursing in Italy was perceived by the students as negative and as adversely affected by the average media portrayal of nursing as a discipline with low levels of professionalism and sometimes linked to fraud and malpractice (Gradellini et al., 2013).
Conclusions The students during their clinical practice are immersed in difficult and complex clinical learning environments. Unfortunately, too often, the journey of becoming a nurse is multifaceted and challenged by faculty and students incivility (Clark, 2008a, 2008b), poor clinical settings and learning environments (Chuan and Barnett, 2012; Lewin, 2006; Papastavrou et al., 2010; Papp et al., 2003) and ineffective organization of mentorship programmes and practice. Moreover, the need for a life-long education for clinical teachers is essential for ensuring nursing students receive appropriate skills in the clinical placements (Burns and Northcutt, 2009).
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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The capacity of the student to consider reflectively the culture of the environment becomes, therefore, fundamental to make the most from the experiences of the clinical learning and this can be accomplished paying attention to the student nurse professional socialization through the key role of the clinical teacher (Brown et al., 2012). Even if, most of student nurses interviewed were prone to ‘do good’, hence, to act with honesty and altruism, it is important to foster these attitudes with positive role models and interconnected and supportive learning environments that inform them to behave in a professional and competent way. For this to be accomplished, it is necessary, in the area under study, to improve the organization of clinical practice environments with dedicated clinical teachers. In these re-organized settings, role models should play an important part in shaping and promote professional respect. Through the perceptions of what students see, feel and put in practice, together with nurses and other health professionals, they co-builds their own professionalism, their professional identity and professional respect. However, the educational context in the area studied is variable and some circumstances have to be considered such as staffing levels, patient acuity, educational qualifications of the existing staff and the clinical teachers' commitment and preparation to the education of undergraduate students (Myrick et al., 2010) all of which can affect the level of learning of the undergraduates. Further research has to be undertaken to explore the issues raised in this study in relation to student nurses awareness of being influenced by contextual and relational forces and further research is also required to more fully understand to what degree the professional behaviors of nurses and other health professionals shape the professional development of nursing students and their professional respect. This study has some limitations; first of all, it was conducted with the participation of students coming from one area of Italy and secondly only students at the entry level were involved. However, the alignment of the findings with other international studies emphasizes the importance of clinical learning placements and effective role models for undergraduates. A final consideration emerges though, of what is the responsibility of all learning system in supporting and promoting student nurses' ability to develop professionalism and the construction of the professional identity and respect. Acknowledgments The authors would like to express their sincere thanks to all the student nurses who participated in this study. We also wish to thank Stefania Andreuccioli for the reflections shared with the project team and Karen Holland (Editor of Nurse Education in Practice) for her useful advice. References Andrew, N., 2012. Professional identity in nursing: are we there yet? Nurse Educ. Today 32, 846e849. Andrews, M., Chilton, F., 2000. Student and mentor perceptions of mentoring effectiveness. Nurse Educ. Today 20, 555e562. Andrews, M., Roberts, D., 2003. Supporting student nurses learning in and through clinical practice: the role of the clinical guide. Nurse Educ. Today 23, 474e481. Baldwin, A., Mills, J., Birks, M., Budden, L., 2013. Role modeling in undergraduate nursing education: an integrative literature review. Nurse Educ. Today. http:// dx.doi.org/10.1016/j.nedt.2013.12.007. Bandura, A., 1977. Social Learning Theory. Prentice-Hall, Englewood Cliffs, NJ. Bradbury Jones, C., Sambrook, S., Irvine, F., 2011. Nursing students and the issue of voice: a qualitative study. Nurse Educ. Today 31, 628e632. Brennan, D., Timmins, F., 2012. Changing institutional identities of the student nurse. Nurse Educ. Today 32, 747e751. Brown, J.A., Stevens, J.A., Kermode, S., 2012. Supporting student nurse professionalisation: the role of the clinical teacher. Nurse Educ. Today 32, 606e610. Burns, H.K., Northcutt, T., 2009. Supporting preceptors: a three-pronged approach for success. J. Contin. Educ. Nurs. 40, 509e513.
Chuan, O.L., Barnett, T., 2012. Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ. Pract. 12, 192e197. Clark, C.M., 2008a. Student voices on faculty incivility in nursing education: a conceptual model. Nurs. Educ. Perspect. 29, 284e289. Clark, C.M., 2008b. The dance of incivility in nursing education as described by nursing faculty and students. Adv. Nurs. Sci. 31, E37eE54. Dante, A., Petrucci, C., Lancia, L., 2013. European nursing students' academic success or failure: a post-Bologna declaration systematic review. Nurse Educ. Today 33, 46e52. Davies, R., 2008. The Bologna process: the quiet revolution in nursing higher education. Nurse Educ. Today 28, 935e942. Del Prato, D., 2013. Students' voices: the lived experience of faculty incivility as a barrier to professional formation in associate degree nursing education. Nurse Educ. Today 33, 286e290. Donaldson, J.H., Carter, D., 2005. The value of role modeling: perceptions of undergraduate and diploma nursing (adult) students. Nurse Educ. Pract. 5, 353e359. Duddle, M., Boughton, M., 2007. Intraprofessional relations in nursing. J. Adv. Nurs. 59, 29e37. Edwards, H., Smith, S., Courtney, M., Finlayson, K., Chapman, H., 2004. Impact of clinical placement location on nursing students competence and preparedness for practice. Nurse Educ. Today 24, 248e255. Federazione Nazionale Collegi IPASVI, 2009. The Nurses' Deontological Code (2009). Available at: http://www.ipasvi.it/static/english/the-nurses-deontologicalcode-2009.htm (accessed 03.12.13.). Federazione Nazionale Collegi IPASVI, 2012. In: I numeri del XVI Congresso Nazionale Ipasvi. Available at: http://www.ipasvitreviso.it/1_I_numeri_del_XVI_ Congresso_nazionale_Ipasvi_-_Federazione_IPASVI.pdf (accessed 03.12.13.). Ferguson, L., 2011. From the perspective of new nurses: what do effective mentors look like in practice? Nurse Educ. Pract. 11, 119e123. Gidman, J., McIntosh, A., Melling, K., Smith, D., 2011. Student perceptions of support in practice. Nurse Educ. Pract. 11, 351e355. Gradellini, C., Idamou, S., Lusetti, S., 2013. Nursing between ethic and aesthetic described by media. Prof. Inferm. 66, 32e38. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24, 105e112. Grealish, L., Ranse, K., 2009. An exploratory study of first year nursing students' learning in the clinical workplace. Contemp. Nurse 33, 80e92. Haigh, C., Johnson, M., 2007. Attitudes and values of nurse educators: an international survey. Int. J. Nurs. Educ. Scholarsh. 4, 14. Hamshire, C., Willgoss, T.G., Wibberley, C., 2012. ‘The placement was probably the tipping point’ e the narratives of recently discontinued students. Nurse Educ. Pract. 12, 182e186. Hartrick Doane, G., 2002. Am I still ethical? the socially-mediated process of nurses' moral identity. Nurs. Ethics 9, 623e635. Henderson, A., Winch, S., Heel, A., 2006. Partner, learn, progress: a conceptual model for continuous clinical education. Nurse Educ. Today 26, 104e109. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., Lloyd, B., 2009. Creating supportive clinical learning environments: an intervention study. J. Clin. Nurs. 19, 177e182. Holland, K., 1999. A journey to becoming: the student nurse in transition. J. Adv. Nurs. 29, 229e236. Keeling, J., Templeman, J., 2013. An exploratory study: student nurses' perceptions of professionalism. Nurse Educ. Pract. 13, 18e22. Kelly, C., 2007. Student's perceptions of effective clinical teaching revisited. Nurse Educ. Today 27, 885e892. Lahtinen, P., Leino-Kilpi, H., Salminen, L., 2013. Nursing education in the European higher education area e variations in implementation. Nurse Educ. Today. http://dx.doi.org/10.1016/j.nedt.2013.09.011. Levett-Jones, T., Lathlean, J., 2009. ‘Don't rock the boat’: nursing students' experiences of conformity and compliance. Nurse Educ. Today 29, 342e349. Lewin, D., 2006. Clinical learning environments for student nurses: key indices from two studies compared over a 25 year period. Nurse Educ. Pract. 7, 238e246. Lipscomb, M., 2012. Abductive reasoning and qualitative research. Nurs. Philos. 13, 244e256. Lundberg, K.M., 2008. Promoting self-confidence in clinical nursing students. Nurse Educ. 33, 86e89. Mansbach, A., Ziedenberg, H., Bachner, Y.G., 2013. Nursing students' willingness to blow the whistle. Nurse Educ. Today 33, 69e72. Moscaritolo, L.M., 2009. Interventional strategies to decrease nursing student anxiety in the clinical learning environment. J. Nurs. Educ. 48, 17e23. Mulholland, S., Derdall, M., Roy, B., 2006. The student's perspective on what makes an exceptional practice placement educator. Br. J. Occup. Ther. 69, 567e571. Myrick, F., Yonge, O., Billay, D., 2010. Preceptorship and practice wisdom: a process of engaging in authentic nursing practice. Nurse Educ. Pract. 10, 82e87. n, J., Segesten, K., 1998. The professional identity of the nurse: concept analysis Ohle and development. J. Adv. Nurs. 28, 720e727. Papastavrou, E., Lambrinou, E., Tsangari, H., Saarikoski, M., Leino-Kilpi, H., 2010. Student nurses experience of learning in the clinical environment. Nurse Educ. Pract. 10, 176e182. Papp, I., Markkanen, M., von Bonsdorff, M., 2003. Clinical environment as a learning environment: student nurses' perceptions concerning clinical learning experiences. Nurse Educ. Today 23, 262e268.
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
L. Sabatino et al. / Nurse Education in Practice xxx (2014) 1e7 Perry, B., 2009. Role modeling excellence in clinical nursing practice. Nurse Educ. Pract. 9, 36e44. Rolfe, G., 1997. Science, abduction and the fuzzy nurse: an exploration of expertise. J. Adv. Nurs. 25, 1070e1075. Rolfe, G., 1998. The theory practice gap in nursing: from research based-practice to practitioner-based research. J. Adv. Nurs. 28, 672e679. Saarikoski, M., Leino-Kilpi, H., 2002. Clinical learning and supervision by staff nurses: developing an instrument. Int. J. Nurs. Stud. 39 (3), 259e267. Sabatino, L., Stievano, A., Kallio, H., Pietila, A.M., Rocco, G., Kangasniemi, M., 2014. The dignity of the nursing profession: a meta-synthesis of qualitative research. Nurs. Ethics. http://dx.doi.org/10.1177/0969733013513215. a, J., 2013. The Coding Manual for Qualitative Researchers. Sage Publications, Saldan Thousand Oaks.
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Skaalvik, M.W., Normann, H.K., Henriksen, N., 2011. Clinical learning environment and supervision: experiences of Norwegian nursing students e a questionnaire survey. J. Clin. Nurs. 20, 2294e2304. ten Hoeve, Y., Jansen, G., Roodbol, P., 2013. The nursing profession: public image, self-concept and professional identity. A discussion paper. J. Adv. Nurs. 70, 295e309. Vaismoradi, M., Salsali, M., Mark, P., 2011. Patient safety: nursing students' perspectives and the role of nursing education to provide safe care. Int. Nurs. Rev. 58, 434e442. Varcoe, C., Doane, G., Pauly, B., Rodney, P., Storch, J., Mahoney, K., McPherson, G., Brown, H., Starzomski, R., 2004. Ethical practice in nursing: working the inbetweens. J. Adv. Nurs. 45, 316e325.
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Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Learning and teaching in clinical practice
Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience Laura Sabatino a, *, Gennaro Rocco b, Alessandro Stievano b, Rosaria Alvaro a a b
Tor Vergata University, Rome, Italy Centre of Excellence for Nursing Scholarship, Ipasvi Rome, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 11 September 2014
This research explored the perceptions of third-year undergraduate nursing students in Italy in relation to the perceptions they had about factors that promoted or diminished the development of professional identity and the professional respect in themselves, and in nursing during their clinical training. Clinical training was meaningful to develop specific knowledge, communication skills, and interpersonal and inter-professional relationships in the area considered. It was also found to be equally important to have good role models to foster the moral development and build a solid professional identity for nursing students. Building a professional identity is an ongoing process and depends on social contexts and on the students' development of the ability to act morally. In this framework, student nurses have to be strongly supported to develop their identity as moral agents in spite of the conflicting demands on them in hostile settings that often do not make them feel respected for their actions. Based on our evidence, we identified two conceptual areas: positive role models and supportive working environments; both have to be strongly connected each other if the student nurses have to develop a strong respect for the ethical values of their profession. © 2014 Published by Elsevier Ltd.
Keywords: Clinical environment Clinical placements Role modeling Student nurses
Introduction The development of professionalism in clinical practice and the n and Segesten, 1998; ten building of professional identity (Ohle Hoeve et al., 2013) is an ongoing process that goes on throughout the individual's professional life, a relational process arising through social contexts (Hartrick Doane, 2002; Varcoe et al., 2004) and student nurses' development of moral identity and of their abilities to act morally are relationally and contextually dependent. It is in the early undergraduate years that this process begins and assume a very strong value for the upcoming years. Good professionalism in practice presumes a process of professional identity construction and professional identity is an important element to gain professional respect (Sabatino et al., 2014). The development of professionalism for nursing, that in Italy for undergraduates take place especially in tertiary health care facilities,
* Corresponding author. E-mail addresses: [email protected] (L. Sabatino), genna.rocco@gmail. com (G. Rocco), [email protected] (A. Stievano), [email protected] (R. Alvaro).
that are still the principal places where students can have their clinical placements, has to be based on positive role models (Donaldson and Carter, 2005) and supportive clinical environments that, through their interconnectedness and strong linkage, play a pivotal role to develop professional behaviors and ethical values. In fact, it is in clinical placements (Edwards et al., 2004; Hamshire et al., 2012) that students learn the required knowledge, together with the technical and relational skills to identify, interpret and cope with the problems of health of the general public (Holland, 1999). In these clinical environments, which enhance their knowledge and skills from qualified nurses and other health professionals and peers, the nursing students learn how to develop strong ethical and professional values. The importance of positive role models (Perry, 2009) on student nurse professional development cannot be overestimated. Some articles on role modeling highlight students' experiences of being exposed to both good and bad role models (Baldwin et al., 2013; Ferguson, 2011; Grealish and Ranse, 2009; Perry, 2009). Students observing an exemplary nurse can convert the observation into a positive action through modeling because, according to the third principle of Bandura's Social Learning Theory:
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“individuals are more likely to adopt a modeled behavior if the model is similar to the observer and has admired status” (Bandura, 1977, p. 30). Despite being fully committed to their practice placement educator role, even the best clinical teachers can be diminished in their role by poor learning environments. Permanent cognitive conflict between theory and practice can lead to the development of insecure identities. The self-awareness of students' own professional respect is still vague and attenuated early in their placements, liable to be detrimental to the nursing profession by remaining subordinate in practice and perpetuating the chasm between theory and practice (Rolfe, 1998). In Italy, the basis of registration for nurses has been a compulsory three-year university degree since 2001 and there has been a marked increase in the professional qualifications of nurses since then. However, despite this raised education experience, the clinical atmosphere is still too often linked to the previous traditional nursing diploma culture and heritage in many clinical learning environments. This relies on the traditional ward routines and other health professions and professionals dictating the rules. As mentorship is widely accepted as a cornerstone for the preparation of professionals in practice it not surprising that in such contexts the students feel unsupported by their clinical facilitators (Andrews and Chilton, 2000; Andrews and Roberts, 2003; Haigh and Johnson, 2007). Within this framework, the aim of this study was to describe the students' perceptions of professionalism in clinical practice and the construction of professional respect through observed behaviors. The participants observed clinical teachers, qualified nurses, student peers and other health professional staff during their clinical placements. There is a compelling need to understand better what prompts the development of professionalism and hence nursing professional respect at an international level, and especially in a country where nursing science still tries to emerge from a deeply ingrained biomedical milieu. Methodology The research design and the main aim of the study was underpinned by three main questions to the students: 1. Can you give an example from your clinical learning setting where professional respect was either violated or regarded as an important value by nursing students? 2. Can you give one example of behavior by some nurses that could be considered as lacking or reinforcing professional respect? Please describe the event. 3. Have you ever witnessed a situation where the behavior of another health professional (physiotherapist, speech therapist, radiographer etc.), support staff or clerical staff either damaged or reinforced nurses' professional respect? Can you give an example?
Research design In this qualitative study we adopted an inductive content a, 2013), analysis approach (Granheim and Lundman, 2004; Saldan using focus groups technique to collect information about the elements which could strengthen or weaken the construction of nursing professional respect from the student nurses points of view.
Ethical approval Prior to the study, written and verbal information was given to the informants about the purpose and nature of the study, emphasizing that participation was voluntary and confidentiality and anonymity was guaranteed. Their right to withdraw without prejudice at any time was also emphasized. Ethical approval was obtained from the Directors of the Nursing Schools involved to conduct the study. Sample The nursing degree programme in Italy is organized according to the credit block system set up by the Bologna Declaration (Dante et al., 2013; Davies, 2008) and during the three years course approximately five months a year are dedicated to theory and six months a year are dedicated to practical clinical training. Clinical learning placements usually begin in general units (internal medicine wards), then move to more complex units (intensive care, neurosurgery, orthopedic surgery otorhinolaryngology, transplant surgery, etc.) and community settings (mental health, home care). In the area considered, community settings are scarcely attended by students. A purposive sample of seventy (n ¼ 70) Italian nursing students, at the conclusion of third year of the nursing degree course, in three different universities, were interviewed. We conducted ten focus groups in eight different nursing schools linked to the main universities in the Roman area. In each focus group there were between 6 and 8 participants. 43 of them were females and 27 were males. This high percentage of males nursing students reflects the trend in Italy who has been showing an increase of the participation of the males in nursing profession in the last 20 years. Nowadays, at the average national level about 24% of the nurses population is composed by male nurses (Federazione Nazionale Collegi IPASVI, 2012) and the situation varies between regions. In the southern areas of the country, due to the high unemployment rates, the nursing workforce population is composed of more than 40% of male nurses in Sicily and Campania just to have some examples (see Table 1). Data analysis A qualitative descriptive approach was used in this study, following Graneheim and Lundman (2004) method of analysis. Content analysis is often used to analyze large amount of narrative data, complex and sensitive phenomena that are multifaceted and difficult to comprehend (Vaismoradi et al., 2011). The focus groups were tape recorded and transcribed verbatim. Subsequently, the text was divided into meaning units that explored the development of professionalism and the meaning of Table 1 Participants' characteristics (n ¼ 70). Universities involved in the area: Tor Vergata University Rome (Italy) e Sapienza University Rome (Italy) e Sacred Heart Catholic University Rome (Italy) Focus groups Participants Student nurses Student nurses Age range Age mean Year of the nursing degree course
10 Total ¼ 70 F ¼ 43 M ¼ 27 21e45 25 3rd
Student placements of clinical practice: intensive care, neurosurgery, orthopedic surgery otorhinolaryngology, transplant surgery, maternity ward, oncology, mental health, urology, etc.
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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professional respect for undergraduates. The meaning units were then coded and grouped together. Initially, many different codes were created, but as the analysis progressed, these were clustered and reduced. Thereafter, sub-categories were formulated and it was then possible to develop four major categories from the subcategories. a, 2013), in the second cycle After this first cycle coding (Saldan coding, two researchers involved in the study repeated reading, reflecting, and validation of codes and categories, moving forwards and backwards between the growing categories and the text. Subsequently, two overarching interlinked themes became evident through a process of abductive analysis (Lipscomb, 2012). Throughout the whole analysis process, the authors compared and discussed the meaning of preliminary codes and categories until consensus was reached. Findings The findings are presented as two major themes, that contribute to develop the perceptions of Italian student nurses on the concept of the development of professionalism and professional respect during their clinical practice: (i) Cultural approach and health professionals' role modeling (ii) Organization of the clinical learning environment. The Fig. 1 provide a synoptic framework of the main categories and the two main emerging themes. Cultural approach and health professionals' role modeling. This theme is composed of three sub-categories: qualified nurses, student peers and other health professionals' role modeling; interprofessional relationships; and social considerations of the image of nurses portrayed by the media. Qualified nurses, student peers and other health professionals' role modeling Observing the behaviors adopted by nurses who worked in wards where students were having their clinical placements allowed the students to build an image of professionalism; students who participated in the interviews observed both negative and
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positive behaviors. Some of the negative behaviors can be easily identified: There were some nurses who shut themselves away in a room while at work, leaving the students alone. They seemed to be discussing their own personal problems. They were heard all over the ward and some patients and relatives came near the room and asked: ‘What's all this shouting about?’. (Focus group 10) The nurse told me to be down-to-earth and hence she wanted me to wash the patient with the same sponge all over the body, even the face. I told her this was not hygienic and she answered me that nurses have to be practical. (Focus group 8) The student nurses witnessed some of the negative behaviors during their learning placements and they felt embarrassed to communicate these during the interviews. There was a nurse … singing, singing, singing … and this lady was dying … she dismissed all the relatives … and still she was singing. (Focus group 2) (A nurse to a student) … ‘To this bloke do like this … with water, because he is a convicted criminal and who knows what he was up to in his life and he doesn't deserve anything’. (Focus group 5) Student nurses affirmed that in a particular unit nurses used two diapers for bed-bound incontinent patients so that they needed to change diapers less frequently and only when both were soaked with liquid: Going into a room, there was a man completely soaking in his urine and that man had double diapers. (Focus group 8) Student nurses related some episodes where they assisted other nurses and affirmed that they were ashamed of having had their clinical practice with these clinical teachers: “(A nurse) … What a bore! And now stop it! It is ten times you are calling, now I'm taking out your bed alarm!” (Focus 5).
Fig. 1. The overarching main themes and categories that contributed to perceive nursing professional respect in nursing students in Italy.
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“Two nurses were making fun of a comatose patient … they were singing lullabies with the name of the patient in front of him” (Focus 1). Often student nurses told some poor episodes involving older or vulnerable patients: “(A nurse) Came near to the bed, put hands on her face and shut her up with profanities” (Focus 6). “The nurses in the early afternoon usually left the elderly patients dirty and their reason was that the nurses in the previous shift had left the patients dirty and they didn't want to do the job of other people!” (Focus 2).
I liked that qualified nurse very much because she showed true professionalism. She administered drugs …. She made a mistake and she took on her responsibilities. (Focus group 6)
Social considerations about images of nurses portrayed by the media The students believed that nurses have a low social status, which harms their professional dignity and that their image is flawed by the media, playing an important role in shaping the nursing profession in society: “(Nurses) They are there slammed in the headlines, under pressure by media, for things that are accomplished by a minority of them” (Focus 6).
Even some behaviors of head nurses are indicated as offensive of the professional respect towards undergraduates and their learning needs:
“The image of the female nurse is linked to the erotic image” (Focus 3).
“Ok, take the broom and sweep over there, take the rags and go to clean windows panes; this is not absolutely dignified for us (student nurses)” (Focus 10).
Sometimes, it is the relatives or significant others of patients that let student nurses be aware that they are not well thought about:
Third year nurse students underlined that the image provided by their peers to the general public is very important to endorse respect for the nursing profession. The behaviors of other student nurses represented an element of great debate in the different focus groups. It is not necessary that you have to go to your clinical practice with full make-up, perfumed, and with long nails, as seems to be common nowadays. (Focus group 10) A student nurse was always coming to clinical practice in a dirty uniform and with dirty hair. Our appearance is reflected in our work. (Focus group 7) Instead of taking care of patients and talking with the patients, this female student nurse told me how she spent her Saturday evening … in front of the patients. (Focus group 9) I saw student nurses follow the example of some senior nurses in disconnecting the bed alarm or to take it away completely. (Focus group 6) During their clinical placements some student nurses tried to see who were the exemplary nurses in order to learn useful skills and avoid being used to carry out mundane activities not suitable for their clinical education: We (students) who are in training have to learn the best from nurses who are offering the best. (Focus group 2) I gave up going on rounds with her (a nurse) because I was ashamed of her. (Focus group 3) The positive behaviors of qualified nurses strengthened the professional respect of the student nurses: That nurse, at the beginning of her shift, always did a complete round of patients to evaluate their conditions. (Focus group 3)
… Fantastic nurses who smiled at patients. They had a way of doing things and behaving that you (student nurse) would have liked to go to the clinical placement every day, even on Sundays. (Focus group 9) (Some nurses) would like you to be integrated and they always try to involve you and often ask: ‘What do you think of this procedure? How would you do it?’. (Focus group 9)
“They call us whistling, maybe they consider us a flock of sheep” (Focus 7). “The nurse is seen as a non-autonomous professional, someone who obeys the physician rules and prescriptions, that is to say, a subordinate, as he/she had not a professional identity” (by patients) (Focus 1).
Organization of the clinical learning environment Clinical learning environment. Student nurses highlighted a series of interconnected strengths and critical points of clinical learning environments that could be matched with the behavior of positive and negative role models in clinical placements. In the clinical learning environment, there are varieties of comportments that can significantly foster and hinder the clinical learning among undergraduates at the entry level. Many students experienced the uneasiness of not being able to behave as they would have liked, in fact, some of them, highlighted different situations where nurses used different procedures. In many cases nurses did not work on evidence based practice or were not aware of the best evidence: “Mercurochrome on pressure ulcers, the nurse gives it to you and you use it even if you know that is not beneficial for the patient, on the contrary, it deteriorates the skin” (Focus 1). “(A student nurse) … While she (a nurse) was beginning to have this technique, I put on gloves and I was told off, because gloves to take a blood sample are not necessary (she said), you can use only gloves to give an i.v. injection” (Focus 9). “The role of the professional … has got its own dignity but this dignity has to be demonstrated in practice. What you study is different from what you see. (Focus 6). An organizational factor was that the student nurses were clearly being treated as members of the workforce rather than persons involved in education: “(A nurse) Very well, it is nice! Students have come and I'm going to take a coffee” (Focus 5). “When we (student nurses) are present in the units, almost no-one answers to the bed bells: ‘Student where are you?’ (nurses shouting)” (Focus 5).
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
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Even the exploitation of student nurses for non-nursing tasks, which have no educational purposes, was noted by students during the focus groups: That person (a head nurse) gives you menial tasks to do, such as cleaning cupboards, and she tells you: ‘When I am coming back I want to see them clean and tidy’. (Focus group 5) To send students to make coffee for everybody in the kitchen or, even to have coffee for everybody at the bar. (Focus group 6)
Discussion The two main themes, a cultural approach and health professionals' role modeling, and the organization of the clinical learning environment (Fig. 1), are strongly interconnected as emerged also in other studies (Mulholland et al., 2006; Papastavrou et al., 2010; Skaalvik et al., 2011). If the organization of clinical teaching fosters the partnership between clinical teachers and students (Saarikoski and Leino-Kilpi, 2002), the students will advance in understanding their professional identity (Andrew, 2012; Brennan and Timmins, 2012) and will be motivated to foster professional values (Keeling and Templeman, 2013). In good clinical working environments the relationship with clinical teachers who can role-model constructive feedbacks is pivotal. This allows students to convert observed behaviors into their own behaviours (Donaldson and Carter, 2005) and in this way nurture confidence and professional respect in undergraduates. The preparation of staff in the clinical area where students are placed is acknowledged as a key component for learning (Henderson et al., 2009). This supports the importance of educating clinical teachers among the most motivated and exemplary health professionals. Excellent workplace learning environments are vital for the development of knowledge and skills of the student nurses. The move to higher education for nursing in Europe (Lahtinen et al., 2013) and worldwide should be reflected in policies that foster the education of competent clinical teachers who can address and eliminate the bad practices and unacceptable moral behaviours in clinical placements and have the students' interests at heart. If sensitively handled, even bad comportments can have a positive influence on undergraduates (Grealish and Ranse, 2009). Supervision is a central element in clinical learning and without staff preparation and commitment to teaching (Andrews and Roberts, 2003) it is difficult to foster and develop in the students a sense of professionalism and professional respect (Brown et al., 2012). Good clinical teachers have sound interpersonal abilities, are clinically competent and are good role models and encourage mutual respect (Kelly, 2007, p.887). This was clearly expressed by the undergraduates' expressions of disgust for bad role models and, conversely, the enthusiasm to see nurses show empathy, compassion, strong moral attitudes and a commitment to accomplishing their work (Donaldson and Carter, 2005). Student nurses have to be strongly supported by dedicated clinical teachers with a good attitude towards them. Effectively partnered relationships are preferable, in order to develop their identity as moral agents in spite of the conflicting demands in difficult settings that often question their ability to feel respected for their actions and that sometimes cause them anxiety and stress (Moscaritolo, 2009). The clinical learning environment with its living models plays a central role in developing professionalism and ethical values, such as professional respect for the nursing profession (Lundberg, 2008). To overcome the theory-practice gap e the chasm between what has been taught and what is practiced in the field e has too often become a source of anxiety.
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These various factors can facilitate the undergraduate students to make sense of acting morally and reflecting critically on their practice situations (Henderson et al., 2006). It is evident that the Italian students in this study experienced a degree of frustration, especially when considering the negative expressions by head nurses and physicians. These models showed a lack of respect for them and for the patients and did not foster professionalism and professional respect. After the students reported such negative behaviors by the staff, school mentors often showed formal concern, but little could have been or was done. The historically and institutionally embedded moral character of these working environments did not allow changing some culturally ingrained ways of acting. Clearly, the challenge in these environments is to develop a pedagogy that can foster student nurses to develop their moral agency and hence the respect for their profession. In these settings, the students expressed that the strengthening of professional respect is generated by the mastery of competencies. They were well aware that the ‘fuzzy nurses’ (Rolfe, 1997) of the millennium are more aware of their rights and have to hold the values associated with competencies in high esteem. In the clinical environments considered, the value of interprofessional collaboration (Duddle and Boughton, 2007) seemed to be a strong factor in showing professional respect. This is noted in the Italian code of ethics for nurses (Federazione Nazionale Collegi IPASVI, 2009). Article 41 states: ‘Nurses collaborate with their colleagues and other health workers, recognizing and valuing their specific contribution within the team’; but this was not evident to the students during their clinical placements. The negative scenario grew worse when the students affirmed that they assisted in the violation of vulnerable persons. They clearly stated that even if they opposed (Bradbury Jones et al., 2011) the attitudes of nurses who wanted them to act against professional values, thus offending the students' professional dignity and behaving as bad role models, the students were mostly unable to withdraw from partaking in improper procedures. All they could do was to tell their mentors of the critical situations they encountered (Levett-Jones and Lathlean, 2009). The fear of a negative evaluation resulting in retribution (Bradbury Jones et al., 2011; Mansbach et al., 2013) sometimes led the students not to express their opinions clearly. Their discontent was then connected to feeling lonely and to learning without proper supervision. The students in this study complained a number of times about the lack of committed clinical teachers who could facilitate the translation of theory into practice (Gidman et al., 2011; Dal Prato, 2013). Finally, the social context of nursing in Italy was perceived by the students as negative and as adversely affected by the average media portrayal of nursing as a discipline with low levels of professionalism and sometimes linked to fraud and malpractice (Gradellini et al., 2013).
Conclusions The students during their clinical practice are immersed in difficult and complex clinical learning environments. Unfortunately, too often, the journey of becoming a nurse is multifaceted and challenged by faculty and students incivility (Clark, 2008a, 2008b), poor clinical settings and learning environments (Chuan and Barnett, 2012; Lewin, 2006; Papastavrou et al., 2010; Papp et al., 2003) and ineffective organization of mentorship programmes and practice. Moreover, the need for a life-long education for clinical teachers is essential for ensuring nursing students receive appropriate skills in the clinical placements (Burns and Northcutt, 2009).
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The capacity of the student to consider reflectively the culture of the environment becomes, therefore, fundamental to make the most from the experiences of the clinical learning and this can be accomplished paying attention to the student nurse professional socialization through the key role of the clinical teacher (Brown et al., 2012). Even if, most of student nurses interviewed were prone to ‘do good’, hence, to act with honesty and altruism, it is important to foster these attitudes with positive role models and interconnected and supportive learning environments that inform them to behave in a professional and competent way. For this to be accomplished, it is necessary, in the area under study, to improve the organization of clinical practice environments with dedicated clinical teachers. In these re-organized settings, role models should play an important part in shaping and promote professional respect. Through the perceptions of what students see, feel and put in practice, together with nurses and other health professionals, they co-builds their own professionalism, their professional identity and professional respect. However, the educational context in the area studied is variable and some circumstances have to be considered such as staffing levels, patient acuity, educational qualifications of the existing staff and the clinical teachers' commitment and preparation to the education of undergraduate students (Myrick et al., 2010) all of which can affect the level of learning of the undergraduates. Further research has to be undertaken to explore the issues raised in this study in relation to student nurses awareness of being influenced by contextual and relational forces and further research is also required to more fully understand to what degree the professional behaviors of nurses and other health professionals shape the professional development of nursing students and their professional respect. This study has some limitations; first of all, it was conducted with the participation of students coming from one area of Italy and secondly only students at the entry level were involved. However, the alignment of the findings with other international studies emphasizes the importance of clinical learning placements and effective role models for undergraduates. A final consideration emerges though, of what is the responsibility of all learning system in supporting and promoting student nurses' ability to develop professionalism and the construction of the professional identity and respect. Acknowledgments The authors would like to express their sincere thanks to all the student nurses who participated in this study. We also wish to thank Stefania Andreuccioli for the reflections shared with the project team and Karen Holland (Editor of Nurse Education in Practice) for her useful advice. References Andrew, N., 2012. Professional identity in nursing: are we there yet? Nurse Educ. Today 32, 846e849. Andrews, M., Chilton, F., 2000. Student and mentor perceptions of mentoring effectiveness. Nurse Educ. Today 20, 555e562. Andrews, M., Roberts, D., 2003. Supporting student nurses learning in and through clinical practice: the role of the clinical guide. Nurse Educ. Today 23, 474e481. Baldwin, A., Mills, J., Birks, M., Budden, L., 2013. Role modeling in undergraduate nursing education: an integrative literature review. Nurse Educ. Today. http:// dx.doi.org/10.1016/j.nedt.2013.12.007. Bandura, A., 1977. Social Learning Theory. Prentice-Hall, Englewood Cliffs, NJ. Bradbury Jones, C., Sambrook, S., Irvine, F., 2011. Nursing students and the issue of voice: a qualitative study. Nurse Educ. Today 31, 628e632. Brennan, D., Timmins, F., 2012. Changing institutional identities of the student nurse. Nurse Educ. Today 32, 747e751. Brown, J.A., Stevens, J.A., Kermode, S., 2012. Supporting student nurse professionalisation: the role of the clinical teacher. Nurse Educ. Today 32, 606e610. Burns, H.K., Northcutt, T., 2009. Supporting preceptors: a three-pronged approach for success. J. Contin. Educ. Nurs. 40, 509e513.
Chuan, O.L., Barnett, T., 2012. Student, tutor and staff nurse perceptions of the clinical learning environment. Nurse Educ. Pract. 12, 192e197. Clark, C.M., 2008a. Student voices on faculty incivility in nursing education: a conceptual model. Nurs. Educ. Perspect. 29, 284e289. Clark, C.M., 2008b. The dance of incivility in nursing education as described by nursing faculty and students. Adv. Nurs. Sci. 31, E37eE54. Dante, A., Petrucci, C., Lancia, L., 2013. European nursing students' academic success or failure: a post-Bologna declaration systematic review. Nurse Educ. Today 33, 46e52. Davies, R., 2008. The Bologna process: the quiet revolution in nursing higher education. Nurse Educ. Today 28, 935e942. Del Prato, D., 2013. Students' voices: the lived experience of faculty incivility as a barrier to professional formation in associate degree nursing education. Nurse Educ. Today 33, 286e290. Donaldson, J.H., Carter, D., 2005. The value of role modeling: perceptions of undergraduate and diploma nursing (adult) students. Nurse Educ. Pract. 5, 353e359. Duddle, M., Boughton, M., 2007. Intraprofessional relations in nursing. J. Adv. Nurs. 59, 29e37. Edwards, H., Smith, S., Courtney, M., Finlayson, K., Chapman, H., 2004. Impact of clinical placement location on nursing students competence and preparedness for practice. Nurse Educ. Today 24, 248e255. Federazione Nazionale Collegi IPASVI, 2009. The Nurses' Deontological Code (2009). Available at: http://www.ipasvi.it/static/english/the-nurses-deontologicalcode-2009.htm (accessed 03.12.13.). Federazione Nazionale Collegi IPASVI, 2012. In: I numeri del XVI Congresso Nazionale Ipasvi. Available at: http://www.ipasvitreviso.it/1_I_numeri_del_XVI_ Congresso_nazionale_Ipasvi_-_Federazione_IPASVI.pdf (accessed 03.12.13.). Ferguson, L., 2011. From the perspective of new nurses: what do effective mentors look like in practice? Nurse Educ. Pract. 11, 119e123. Gidman, J., McIntosh, A., Melling, K., Smith, D., 2011. Student perceptions of support in practice. Nurse Educ. Pract. 11, 351e355. Gradellini, C., Idamou, S., Lusetti, S., 2013. Nursing between ethic and aesthetic described by media. Prof. Inferm. 66, 32e38. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24, 105e112. Grealish, L., Ranse, K., 2009. An exploratory study of first year nursing students' learning in the clinical workplace. Contemp. Nurse 33, 80e92. Haigh, C., Johnson, M., 2007. Attitudes and values of nurse educators: an international survey. Int. J. Nurs. Educ. Scholarsh. 4, 14. Hamshire, C., Willgoss, T.G., Wibberley, C., 2012. ‘The placement was probably the tipping point’ e the narratives of recently discontinued students. Nurse Educ. Pract. 12, 182e186. Hartrick Doane, G., 2002. Am I still ethical? the socially-mediated process of nurses' moral identity. Nurs. Ethics 9, 623e635. Henderson, A., Winch, S., Heel, A., 2006. Partner, learn, progress: a conceptual model for continuous clinical education. Nurse Educ. Today 26, 104e109. Henderson, A., Twentyman, M., Eaton, E., Creedy, D., Stapleton, P., Lloyd, B., 2009. Creating supportive clinical learning environments: an intervention study. J. Clin. Nurs. 19, 177e182. Holland, K., 1999. A journey to becoming: the student nurse in transition. J. Adv. Nurs. 29, 229e236. Keeling, J., Templeman, J., 2013. An exploratory study: student nurses' perceptions of professionalism. Nurse Educ. Pract. 13, 18e22. Kelly, C., 2007. Student's perceptions of effective clinical teaching revisited. Nurse Educ. Today 27, 885e892. Lahtinen, P., Leino-Kilpi, H., Salminen, L., 2013. Nursing education in the European higher education area e variations in implementation. Nurse Educ. Today. http://dx.doi.org/10.1016/j.nedt.2013.09.011. Levett-Jones, T., Lathlean, J., 2009. ‘Don't rock the boat’: nursing students' experiences of conformity and compliance. Nurse Educ. Today 29, 342e349. Lewin, D., 2006. Clinical learning environments for student nurses: key indices from two studies compared over a 25 year period. Nurse Educ. Pract. 7, 238e246. Lipscomb, M., 2012. Abductive reasoning and qualitative research. Nurs. Philos. 13, 244e256. Lundberg, K.M., 2008. Promoting self-confidence in clinical nursing students. Nurse Educ. 33, 86e89. Mansbach, A., Ziedenberg, H., Bachner, Y.G., 2013. Nursing students' willingness to blow the whistle. Nurse Educ. Today 33, 69e72. Moscaritolo, L.M., 2009. Interventional strategies to decrease nursing student anxiety in the clinical learning environment. J. Nurs. Educ. 48, 17e23. Mulholland, S., Derdall, M., Roy, B., 2006. The student's perspective on what makes an exceptional practice placement educator. Br. J. Occup. Ther. 69, 567e571. Myrick, F., Yonge, O., Billay, D., 2010. Preceptorship and practice wisdom: a process of engaging in authentic nursing practice. Nurse Educ. Pract. 10, 82e87. n, J., Segesten, K., 1998. The professional identity of the nurse: concept analysis Ohle and development. J. Adv. Nurs. 28, 720e727. Papastavrou, E., Lambrinou, E., Tsangari, H., Saarikoski, M., Leino-Kilpi, H., 2010. Student nurses experience of learning in the clinical environment. Nurse Educ. Pract. 10, 176e182. Papp, I., Markkanen, M., von Bonsdorff, M., 2003. Clinical environment as a learning environment: student nurses' perceptions concerning clinical learning experiences. Nurse Educ. Today 23, 262e268.
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
L. Sabatino et al. / Nurse Education in Practice xxx (2014) 1e7 Perry, B., 2009. Role modeling excellence in clinical nursing practice. Nurse Educ. Pract. 9, 36e44. Rolfe, G., 1997. Science, abduction and the fuzzy nurse: an exploration of expertise. J. Adv. Nurs. 25, 1070e1075. Rolfe, G., 1998. The theory practice gap in nursing: from research based-practice to practitioner-based research. J. Adv. Nurs. 28, 672e679. Saarikoski, M., Leino-Kilpi, H., 2002. Clinical learning and supervision by staff nurses: developing an instrument. Int. J. Nurs. Stud. 39 (3), 259e267. Sabatino, L., Stievano, A., Kallio, H., Pietila, A.M., Rocco, G., Kangasniemi, M., 2014. The dignity of the nursing profession: a meta-synthesis of qualitative research. Nurs. Ethics. http://dx.doi.org/10.1177/0969733013513215. a, J., 2013. The Coding Manual for Qualitative Researchers. Sage Publications, Saldan Thousand Oaks.
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Skaalvik, M.W., Normann, H.K., Henriksen, N., 2011. Clinical learning environment and supervision: experiences of Norwegian nursing students e a questionnaire survey. J. Clin. Nurs. 20, 2294e2304. ten Hoeve, Y., Jansen, G., Roodbol, P., 2013. The nursing profession: public image, self-concept and professional identity. A discussion paper. J. Adv. Nurs. 70, 295e309. Vaismoradi, M., Salsali, M., Mark, P., 2011. Patient safety: nursing students' perspectives and the role of nursing education to provide safe care. Int. Nurs. Rev. 58, 434e442. Varcoe, C., Doane, G., Pauly, B., Rodney, P., Storch, J., Mahoney, K., McPherson, G., Brown, H., Starzomski, R., 2004. Ethical practice in nursing: working the inbetweens. J. Adv. Nurs. 45, 316e325.
Please cite this article in press as: Sabatino, L., et al., Perceptions of Italian student nurses of the concept of professional respect during their clinical practice learning experience, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.09.002
